Allergic Reaction to Vanadium Causes a Diffuse Eczematous Eruption and Titanium Alloy Orthopedic Implant Failure
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CONTACT DERMATITIS Allergic Reaction to Vanadium Causes a Diffuse Eczematous Eruption and Titanium Alloy Orthopedic Implant Failure Sally Engelhart, BA; Robert J. Segal, MD PRACTICE POINTS • Vanadium may be an underrecognized allergen in patients with metalcopy implants. • Consider vanadium allergy in those with surgical implants and signs of hypersensitivity reaction. • Test for allergy with vanadium trichloride. • Niobium is an alternative for implants in vanadium-allergic patients. not Allergy as a cause of adverse outcomesDo in their different microstructures, contributing to patients with implanted orthopedic hardware is the release of vanadium in vivo. The patient was controversial. Allergy to titanium-based implants patch tested with several metals including com- has not been well researched, as titanium is tradi- ponents of the implant and had a positive patch tionally thought to be inert. We highlight the case test reaction only to vanadium trichloride. These of a patient who developed systemic dermatitis findings support a diagnosis of vanadium allergy and implant failure after surgical placement of a and suggests that clinicians should consider titanium alloy (Ti6Al4V) plate in the left foot. The including vanadium when patch testing patients hardware was removed andCUTIS the eruption cleared with a suspected allergic reaction to vanadium- in the following weeks. The plate and screws containing implants. were submitted for metal analysis. The elemental Cutis. 2017;99:245-249. composition of both the plate and screws included 3 major elements—titanium, aluminum, and vanadium—as well as trace elements. Metal anal- etal allergy in patients with orthopedic ysis revealed that the plate and screws had differ- implants can cause serious problems includ- ent microstructures, and electrochemical studies Ming dermatitis and implant failure.1 As life demonstrated that galvanic corrosion could have expectancy increases, the general population ages, occurred between the plate and screws due to and more metallic orthopedic implants are placed,2 allergy to these implants is expected to be a problem of greater significance. Uncertainty remains regard- Ms. Engelhart is from Harvard Medical School, Boston, ing best practice for patients with suspected metal Massachusetts. Dr. Segal is from the Division of Dermatology, implant allergy.1 The major questions are: Who University of Arizona, Tucson. should be tested? When should they be tested? What The authors report no conflict of interest. 3-8 Correspondence: Robert J. Segal, MD, Division of Dermatology, are the optimal tests to diagnose metal allergy? University of Arizona, 3838 N Campbell Ave, Tucson, AZ 85719 We report the case of a patient with vana- ([email protected]). dium allergy who developed a diffuse eczematous WWW.CUTIS.COM VOLUME 99, APRIL 2017 245 Copyright Cutis 2017. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. Contact Dermatitis dermatitis and implant failure after receiving a The patient had persistent pain and swelling vanadium-containing titanium alloy orthopedic at the surgical site, and radiographs taken post- implant in the left foot. This case is remarkable operatively at 6 months showed implant failure because hypersensitivity reactions to titanium-based (Figure 3). The hardware was surgically removed hardware are rare, as they traditionally have not 8 months after implantation (Figure 4) and the been thought to provoke allergic reactions.9 plate and screws were submitted to the Institute for Mineral Resources Geosciences LA-ICP-MS Facility Case Report and the Lunar and Planetary Laboratory at the A 62-year-old woman who was otherwise healthy University of Arizona (Tucson, Arizona) for analy- presented with an eruption of more than 80 pruritic, sis. The skin lesions began to improve days after the nummular, eczematous plaques on the arms, legs, hardware was removed and the eruption cleared over back, and buttocks of 3 weeks’ duration (Figure 1). the following 3 weeks with no additional treatment. She had a history of allergy to metal used in costume After the hardware was removed, it was analyzed jewelry. Six weeks prior, the patient underwent to determine the elemental composition of the plate implantation of a titanium alloy plate in the left and screws, and the patient was then patch tested foot for surgical repair of painful deforming osteo- with the major metal components of the implant: arthritis. A radiograph of the foot showed appro- aluminum chloride hexahydrate 2.0% pet, elemental priate placement. According to the manufacturer, titanium 10.0% pet, titanium dioxide 10.0% pet, the plate was composed of the compound Ti6Al4V, titanium (III) nitride 5.0% pet, titanium (III) oxalate which contained 90% titanium, 6% aluminum, and 4% vanadium. The lesions developed on the skin close to but not directly over the surgical site. copy A punch biopsy of one of the lesions on the shoulder showed lymphoeosinophilic spongiosis consistent with a delayed hypersensitivity reaction (Figure 2). There was mild clinical improvement of not the eruption with topical steroids. A course of pred- nisone for systemic effect resulted in clearing of the eruption, but it promptly recurred on cessation of the steroids. The patient was then patch tested usingDo the North American 80 Comprehensive Series, with an additional 59 common textile, shampoo, fragrance, and several metal allergens, all of which were negative. A CUTIS B Figure 2. Vanadium allergy histopathology from a punch A B biopsy of a lesion showing lymphoeosinophilic spon- giosis (A) and numerous eosinophils (B)(H&E, original Figure 1. Vanadium allergy with eczematous plaques on magnifications ×10 and ×40). Photographs courtesy of the left leg (A) and right thigh (B). Keliegh Culpepper, MD (Tucson, Arizona). 246 CUTIS® WWW.CUTIS.COM Copyright Cutis 2017. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. Contact Dermatitis decahydrate 5.0% pet, elemental vanadium 5.0% pet, and vanadium (III) chloride 1.0% pet. She demon- Table 1. strated a 1+ reaction (erythema and induration) to Major Components Determined by vanadium trichloride at 72 and 96 hours. The plate and screws removed from the patient Electron Microprobe Analysis were sterilized and submitted for analysis. Electron Plate, Screws, microprobe analysis confirmed that the major ele- Metal wt/wt wt/wt mental composition of the plate and screws essen- tially matched the manufacturer’s listing (Table 1). Titanium 90.005 90.260 The trace elements were determined using laser abla- Aluminum 6.243 6.348 tive inductively coupled mass spectroscopy, which Vanadium 4.025 3.829 demonstrated that the screws were of different metal composition from the plate (Table 2). Electron microprobe analysis also was used to determine the microstructure of the plate and screws. The plate had referred to simply as titanium, but the distinction is 2 distinct phases consisting of a titanium-aluminum important when it comes to medical implants and phase and a vanadium phase, whereas the screw was devices. Commercially pure titanium is more than much more homogeneous. Basic electrochemical 99% pure titanium, but up to 1% of its volume can studies were performed in a salt solution replicat- be comprised of impurities.10 In titanium alloys, ing the tissue of the foot. These studies showed that the alloy elements are intentionally added to cre- galvanic corrosion could have occurred between the ate a material with optimal properties. The 2 most plate and screws due to the differences of composition. common types copyof titanium that are used for ortho- pedic implants are cp-Ti and Ti6Al4V, a titanium Comment alloy containing approximately 90% titanium, Titanium is an attractive metal to use in orthopedic 6% aluminum, and 4% vanadium. Similar to cp-Ti, implants. It has a high strength-to-weight ratio, a titaniumnot alloys also can contain impurities such as low modulus of elasticity, and good resistance to cor- aluminum, beryllium, cobalt, chromium, iron, nickel, rosion. Titanium can be categorized as either com- and palladium, among many others. Although these mercially pure titanium (cp-Ti) or a titanium alloy. impurities often are considered negligible from a Colloquially, both cp-Ti and titanium alloys are oftenDo metallurgy perspective, as they do not change the CUTIS Figure 3. Radiograph of the left foot prior to removal of Figure 4. Surgical hardware containing vanadium the implant showed implant failure due to vana- after removal from a patient who demonstrated an aller- dium allergy. gic reaction. WWW.CUTIS.COM VOLUME 99, APRIL 2017 247 Copyright Cutis 2017. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. Contact Dermatitis Vanadium is known to be allergenic, especially Table 2. in the presence of implant failure.12,13 In our patient, Trace Elements Determined by patch testing with more than 100 allergens was negative, except for vanadium trichloride 1%. Our Laser Ablative Inductively Coupled patient’s presentation strongly suggested that she Mass Spectroscopy developed a vanadium allergy manifesting as sys- temic allergic contact dermatitis. She demonstrated Element Plate, ppm Screws, ppm no history of skin disease, a widespread eczema- Silicon 1739.000 2497.000 tous eruption after exposure, histology consistent Iron 1741.834 1857.000 with systemic contact allergy, a positive patch test Sulfur 309.533 686.489 to vanadium, and clearance of the eruption on removal of the antigen, which have been proposed Nickel 89.860 107.200 as objective criteria that support a diagnosis of metal Chromium 152.800 80.373 implant allergy.14 She refused our suggestion to reim- Zinc 36.968 46.310 plant a portion of the remaining plate under the Copper 34.570 42.640 skin without screws and monitor for recurrence of Molybdenum 5.680 32.090 the eruption. She did not have a lesion overlying the surgical site, but she did develop lesions near the Tin 3.727 25.890 surgical scar.